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John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I love when my readers send me emails that are basically a blog post. Especially when they ask in that email to shed more light on a certain subject. Below you’ll find one such email. I’ve made it anonymous since the particular vendor doesn’t matter too much, but it’s an interesting read from an EMR vendor’s perspective.

My comment is that ONC was given the impossible task of trying to create “meaningful use” guidelines that were in fact meaningful. The concept of paying doctors for actually using the EMR is a good one, but measuring and regulating that is much harder. I’m sure many of you will enjoy the following comments about some of the meaningful use guidelines.

Some of my guys were going over the Meaningful Use requirements to feed the developers their next tasks and realized that we had missed a HUGE piece of functionality. That functionality is the Status of a “problem.” Apparently a “problem” can exist in three states: active, inactive or resolved. Notice the term “problem” is in quotes. First, there are no “problems” there are complaints, diagnoses and treatments. If there were a “problem” it would be something like “chest pain” not “essential hypertension.” The use of the word “problem” starts me down the path that the government doesn’t have a clue as to what this is or how it should work. The icing on the cake is that you don’t have diagnoses that exist in the three states that are mentioned above. Once a diagnoses has been made, the patient responds to treatment and gets better or s/he dies. This reminds me a little bit of your blog about documenting by exception. You get a ream of notes that aren’t relevant at all with every visit. Like that, if you have say chronic obstructive pulmonary disease as outlined in §170.302c, it doesn’t go away. It is a CHRONIC condition and as such will not ever be marked as inactive or resolved. The way I see it there are two kinds of visits, chronic and episodic. If I break my arm and I go get it set and have a cast put on it. This is episodic. If I have diabetes, I have to go for a visit every so often to get it checked out and maybe adjust my treatments. This is chronic. Either way, there is no doctor that is going to go back in to his own notes and mark either of these resolved or inactive on subsequent visits. That propels me far down the path of thinking that nobody making these rules really knows what they are doing. I mean the growth charts were a little piece of functionality that was difficult at best, and showed that these people don’t have the faintest idea about programming, but at least they add value.

I am seriously considering not even attempting certification for these and some of the reasons you have stated in your blog. Here is the real reason for my email: I would like to see a blog about this in the near future. Someone needs to raise his or her hand and cry “foul” before these idiots make more rules that have no meaning and only annoy those of us who do understand what is going on and what we are doing.

13 responses to "An EMR Vendor’s View of the Meaningful Use Requirements"

We need two separate categories of ACUTE and CHRONIC problems. Among those are the active, inactive subcategories.

The whole “PROBLEM ORIENTED MEDICAL RECORD” with the SOAP notes was invented in Cleveland about 40 or so years ago to deal with medical residents rotating through “clinics” where they would see a patient and upon return, some other medical resident would see them. It was an attempt to provide some structure to the out-patient visit note.

It is still useful for chronic care. A PROBLEM may be a diagnosis or a symptom. CMS decreed years ago that they wanted “diagnoses, at the highest level of specificity.” That was a nice try and a good bureaucratic objective, but it was not the real world of everyday seeing people come for appointments with the internist or general practitioner.

Doc Jim,
I think that’s the problem. The challenge of balancing, the theoretical, the bureaucratic and the practical real world. I personally error on the side of real world practical details, but I know many EMR and EHR vendors have had to change a whole development cycle just to deal with the bureaucratic realities of meaningful use and EHR certification.

Completely agree with the vendor. He or she knows how absurd the approaches to meaningful use are, which are being programmed into these silly systems that generate garbage notes. Hmmm…. garbage notes. Think that would make a good blog. I personally hate them, but of course, I myself cite them to get the silly points one needs to bill at higher levels to get increasingly piddly reimbursement from insurance companies. Ah, yet another blog!

So which is better: allowing 300-odd EHR vendors to come up with their own jargon in an attempt to codify clinical workflows, or to have a centralized authority (in this case, the ONC) develop one standardized approach which is based on input from the public during open comment periods, and from the vendors themselves?

And who says that the EHR vendor who authored this comment is in a better position to tackle these challenges than the EHR vendor across the street?

We simply can’t improve quality of care across-the-board in this country unless we attempt, somewhere, somehow, to standardize at least part of the workflows and cross-provider communications that are going on out there. There’s too much noise right now, and non-standardized lexicons used by 300 EHR vendors aren’t helping matters.

Addressing Glenn’s concern: Government bureaucrats will never be able to work out the details of such a complex task, largely because they have no real “stake in the game”. The EMR vendors need to understand that their future success depends on their funding their own IEEE-like organization and supplying personnel to support standards agreed to by the majority. Firefox and other browser makers have to adhere to upcoming HTML5 guidelines or perish. Why would EMR vendors not see the correlation to their own problem?

Glen,
I would have been happier had the government tried to create a standard for the cross provider communication. I agree that they could have possibly added value to that part of the equation. The problem is that their standards go well beyond just interoperability.

It’s certainly possible that the EMR vendor who wrote the comments above isn’t positioned to tackle these challenges better than another EMR vendor. Although, that’s the beauty of business is that the customers will evaluate and decide if they do or not.

David,
I agree that an organization like that would be good. The problem is that the EHR vendors kind of tried that and ended up with the atrocity called CCHIT. They went too far with CCHIT and that was part of the downfall I think. Although, it seems like HL7 and CCD are going to control the standard going forward.

Coincidentally, I actually came up with the exact same conclusion when reviewing the specs the other day. What I mean is, I identified that the way that we track “problems” in our software serves our customers well, but doesn’t really meet the measurement method of Meaningful Use.

In my app, I can record a “problem” using an ICD-9 code on the patient record (chronic) as well as on the visit (acute/episodic, based on Dx attached to the charges posted for that encounter). I also track descriptive (non-standardized) phrases in our Medical History. The former is good because it meets the standardized terminology requirement, but it fails because I don’t keep a “history” of active, or inactive problems. The latter is good because it is more “all encompassing”, including problems that the patient isn’t actually being seen by this particular doctor for, but also fails because it isn’t recorded by ICD-9 code and descriptor.

Either way, I have to revise the software’s method of recording “problems”, both for historical purposes and for proper coding, and ONLY to meet the Meaningful Use requirement. Not a single customer has ever voiced a request remotely like this to me in my 12 years of handling software in this sector.

“Finishing last in three successive parades had given Lieutenant Scheisskopf an unsavory reputation, and he considered every means of improvement, even nailing the twelve men in each rank to a long two-by-four beam of seasoned oak to keep them in line.

The plan was not feasible, for making a ninety-degree turn would have been impossible without nickel-alloy swivels inserted in the small of every man’s back, and Lieutenant Scheisskopf was not sanguine at all about obtaining that many nickel-alloy swivels from Quartermaster or enlisting the co-operation of the surgeons at the hospital”.

[…] Especially since I know many of you don’t read all the comments (shame on you). This comment on meaningful use comes from someone who identifies themselves as SoftwareDev and works for an EMR vendor: […]

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